Volunteers under the age of 18 are required to provide a signed waiver that includes the signature of a parent or guardian.

Volunteers age 16-17 as of June 7, 2019: We will accept a limited number of volunteers between the ages of 16-17. A waiver signed by a parent or guardian is required. Volunteers age 16-17 can only be assigned to a NON-clinical area approved by the MOM-n-PA staff. Volunteers under the age of 18 cannot work on the clinic floor.

Volunteers age 14-15: Each youth age 14-15 must be supervised at the event by a parent or guardian who is also registered as an MOM-n-PA 2013 volunteer and who will take full responsibility for the youth during the event. Enter the name of your parent or guardian who is also an MOM-n-PA 2013 volunteer.

Volunteers age 16-17 do not have to have a parent/guardian on site, but we must have a signed waiver on file before those volunteers can be allowed to work at MOM-n-PA.

After this Waiver is printed, filled out, and signed, it may be scanned and sent as a PDF file to volchair@mom-n-pa.com. Or it may be mailed to Dr. Ronald Heier at 1405 Allan Lane, West Chester, PA 19380

Under-age Volunteer’s Name: ___________________________­­­_________________

Under-age Volunteer’s Address: ___________________________­­­_______________

Under-Age Volunteer birth date, including year:  (mm/dd/yyyy) __________________       

Age of Volunteer on June 7, 2019: ____. Date of birth _______________

__ I grant permission for this under-age volunteer to work at MOM-n-PA 2019 and accept full responsibility for this volunteer’s actions.

__ I am the adult parent or guardian of the under-age volunteer named above.

Adult Parent or Guardian Name (print): __________________________________

Adult Parent or Guardian Signature: ____________________________________

Adult Parent or Guardian Phone #s: ____________________________________

Adult Parent or Guardian Email: _______________________________________    

Date Signed: ________________________